Michael McMurray, DC Campbell, CA presentation at San Jose Cox Seminar September 2013 History A 13 year old girl who plays club soccer develops insidious onset of back pain. Symptoms start in Anterior groin and progress to central lower back. Pain becomes debilitating, and patient has to stop all sport and drop out of school. She is home schooled. 1
Initial treatment Patient goes to Stanford Pain Clinic. Referred to P.T. who does McKenzie therapy that makes her worse. Goes to Acupuncturist and Osteopath with minimal results. Put on Ambien and N.S.A.I.D. that cause severe liver and G.I. problems. Patient lost 35 lbs. Treatment cont. Stanford Pain Clinic does radio frequency nerve ablation therapy. Patient receives relief for 6 weeks. Pain returns. Second round gives her some relief for 2 years. Pain returns. The patient has Facet Injections. Relief lasts for 6 weeks. Second round had no effect. 2
Patient presents to my office Symptoms include: 3 out of 4 pain level from Spinous processes of L1 to the Sacrum. She describes the pain as aching and stabbing. She also describes bilateral L5 nerve distribution pain in the lateral thighs and aching and numbness to the lateral compartment of the lower leg, left greater than the right. Significant Exam findings R.O.M. Flexion 80 deg. sharp L2 and L4 pain Extension 10 degrees sharp L4 pain Rt. Lat. Flexion 30 degrees increases LLBP Lt. Lat. Flexion 40 degrees negative Rotation left increase LLBP. Right negative. SLR right and left increased Central LBP Kemps Rt. and Lt. increased Central LBP 3
Exam findings continued Valsalva s positive increasing central LBP Bechterrew s increased central LBP Lindner s increased central LBP Sharp pain upon Palpation over the Spinous processes of L3 which shot pain to the buttocks bilaterally Sharp L3, L4 and L5 pain upon palpation Neurology and Motor within normal limits Plain film study Mild loss of L4-L5 disc height Femoral head and Iliac crest 10mm lower on left 12 degree left lateral convexity from L3 to T11 30 degree sacral base angle (Hypolordosis) Slight L4 retrolisthesis 4
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MRI Study Lumbar MRI Impressions: L4-L5 degenerative disc disease accompanied by a broad based left paracentral posterior protrusion. Early L5-S1 DJD Synovial cyst adjacent to the posterior margin of the right L2-L3 facet articulation and spinolaminar arch. Smaller cyst on left. 6
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Diagnosis 1. L4-L5 Degenerative Disc Disease 2. Left Medial L4 disc protrusion 3. Right L2-L3 Synovial Cyst 8
Treatment Cox Flexion Distraction Decompression using Disc Protocol I at L4 with the caudal section of the table in slight left lateral flexion Cox Flexion Distraction Decompression Disc Protocol I at L2 for treatment of the synovial cyst Full Spine Activator adjusting following Activator Protocol Treatment Continued Interferential muscle stimulation over the L4-L5 Disc for 20 with Ice and patient in the supine position with her legs over a chair and her buttocks under the chair approximating her knees to her chest Active Release Technique to her Psoas, Piriformis and Superior Gammelus muscles bilaterally. Iliolumbar ligament bilaterally 9
Exercises Home care exercises included: Pelvic tilts, single knee chest, double knee chest, planks, Ball exercises include seated march, cross crawl crunches, bridge, airplane and superman Home care icing with patients legs over a chair with the ice pack across the lower back and the chair pulled toward her buttock. Clinical Outcome The patient had 7 treatments before she starts to receive significant relief. She had a total of 17 treatments from January 30, 2009, to March 26, 2009. This is a 55 day period of time. She was seen for follow-up and flareups 13 times between March 2009 and January 2010. She has presently been stable for 3 years. 10
Outcome continued She is 23 years of age at this time. She has graduated from a prestigious California University in kinesiology. She plays tennis and has a relatively normal life without any lower back reoccurrences. She has had a complete recovery of her disc protrusion and synovial cyst. 11